The Peter Attia Drive

In this "Ask Me Anything" (AMA) episode, Peter and Bob take a deep dive into fat flux. They define the major players that impact the flow of fat entering and exiting a fat cell, which determines how much fat a person carries. They discuss the significant influence that insulin has on the net fat balance and explore common strategies, such as fasting and low-carb diets, that have efficacy in the liberation and oxidation of fat from fat cells. Additionally, Bob explains his research process and how he seeks answers to Peter's challenging questions.

If you're not a subscriber and listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #22 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

• The two main ways to reduce fat mass (1:30);
• Explaining fat flux—how fat enters and exits a fat cell (9:15);
• What fat balance looks like (21:15);
• What net fat influx looks like, and the impact of insulin in lipolysis (24:30);
• What net fat efflux looks like, and the benefits of fasting to break the hyperinsulinemic cycle (28:30);
• Exploring why most people with excess body fat will lose fat mass when reducing carbohydrates or eating a ketogenic diet (32:45);
• Why being in nutritional ketosis does not automatically translate to negative fat flux (fat loss) (42:40);
• Bob's approach to scientific research (47:00);
• The importance of curiosity and a desire to learn (58:30);
• Bob's tips and tricks for answering a scientific question in a time-crunch (1:00:00); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/ama22/ Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Jake Muise is an avid hunter, environmentalist, and advocate for the preservation of Hawaii's natural resources. He is the founder of Maui Nui Venison, a company which actively manages Hawaii's imbalanced population of axis deer by harvesting them as a food resource. In this episode, Jake tells his unbelievable backstory growing up in Northern Alberta before landing in Hawaii on a volleyball scholarship where he fell in love with the islands and the people. Jake explains how axis deer—a non-native species—were brought to the islands and how they have since become imbalanced to the detriment of Hawaii's precious ecosystems. He goes on to explain the incredible lengths that his company has taken to ensure the most humane harvesting techniques imaginable resulting in a food source that is as clean and healthful as can be. Additionally, Jake and Peter examine what makes meat from axis deer one of the most nutrient-dense red meats on the planet.

We discuss:

• Upbringing in Northern Alberta, a diet of moose meat, and learning to surf in Nova Scotia (3:35);
• How volleyball brought Jake to Hawaii where he met the Molokai people (14:00);
• Jake's introduction to axis deer (26:30);
• Pro volleyball in Europe, missing the Olympic team by one spot, and his return to Hawaii (29:00);
• History of axis deer in Hawaii—how a non-native species came to the islands, and the superpowers that make them so hard to hunt (34:00);
• A potential catastrophe avoided on The Big Island—The amazing story of how Jake tracked and found axis deer that were secretly brought to The Big Island (52:15);
• Jake's work helping ranchers on Maui (1:08:15);
• The detrimental impact of an imbalanced axis deer population (1:10:30);
• The incredible evacuation of farm animals from lava-locked land due to a volcano eruption (1:17:00);
• The creation of Maui Nui Venison—going above and beyond USDA requirements (1:27:00);
• The most humane way to harvest an animal—the unmatched standards Maui Nui Venison uses to harvest axis deer (1:32:00);
• Why meat from axis deer is nutritionally superior (and tastes better) than other meats (1:46:00);
• Why axis deer meat is the best option for those reluctant to eat meat: True nose-to-tail nutrition and ethical harvesting (1:58:15);
• What a truly balanced population of axis deer on Hawaii would look like (2:06:15);
• Maui Nui Venison's charitable work during the COVID crisis (2:12:45); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/jakemuise Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Chris Sonnenday is the Transplant Center Director for Michigan Medicine. As Peter's senior resident while at Johns Hopkins, Chris made a lasting impression on him with his remarkable leadership and ability to maintain his humanity through the stressors of that challenging environment. In this episode, Chris tells the incredible backstory of the history of transplant medicine, focusing on the kidney and the liver. He discusses the surgical and immunologic developments that launched the field forward, but also lays out the challenges ahead for the field, such as the rising prevalence of chronic kidney and liver failure. Chris also tells many stories of tragedy and triumph that comes with working in organ transplantation, but ultimately explains the rewarding nature of being a witness to the gift of organ donation.

We discuss:

• What attracted Chris to medicine, and his leadership in residency (3:30);
• How Chris maintained his empathy and humanity through the stresses of med school and residency (8:30);
• Why Chris chose a complicated field like transplant medicine (23:15);
• Explaining kidney transplantation to showcase the challenge of organ transplantation surgery (28:00);
• Overcoming the immune-based challenges of transplant surgery (37:00);
• How the discovery of cyclosporine transformed the field of organ transplantation (49:00);
• Rising chronic kidney failure due to the prevalence of pre-diabetes and metabolic syndrome (53:45);
• Why living kidney donations are superior, and the possibility of a market for kidney donation (59:30);
• Designing a fair system of organ distribution (1:17:30);
• The debate on what constitutes "death" when deciding when to take organs from a registered organ donor (1:21:45);
• Reflections on the gift of organ donation (1:33:15);
• The history of liver transplantation and why it's so complex (1:39:15);
• Addressing acute liver failure and the amazing baboon experiment (1:46:15);
• The potential for the rising prevalence of NAFLD and NASH to overwhelm the liver transplant infrastructure in the US (1:54:45);
• The importance of teamwork in successful organ transplantations, and the most tragic event Chris has ever witnessed (2:05:45); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: http://peterattiamd.com/ChrisSonnenday Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Steven Levitt is a professor of economics at the University of Chicago and the co-author of the bestselling book Freakonomics and its two sequels. In this episode, Steve discusses his unlikely path to a career in economics and his view of the current state, and limitations, of the field. He also gives his unique perspective on contemporary issues including climate change, mental health in education, how to evaluate whether an experiment is ethical, decision making, horse racing, and much more.

We discuss:

• How Steve ended up in economics (2:45);
• Current trends in the field of economics: macro vs. micro, usefulness of models, and the relationship between data and theory (8:45);
• Revisiting what Steve wrote about climate change in SuperFreakonomics, and why it's unlikely to be solved with behavioral change (18:45);
• The consequences of a blurred line between climate science and advocacy (27:30);
• Answering climate questions with a "Manhattan Project for climate change" (31:45);
• Steve's reflections on his career path and how he found his way by being himself (40:00);
• How Steve came to write Freakonomics (and its sequels), and the topics which caused the most controversy (53:00);
• How Steve came to appreciate mental health through parenting, and the need to emphasize mental health into the education system (1:10:15);
• Why people are bad at making decisions (1:26:45);
• Deliberating on why horse racing times haven't advance much in decades (1:34:30);
• Reducing the impact of negative emotions by observing the world free of language (1:44:00);
• Changing our thinking about what it means to conduct experiments ethically (1:49:00); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/SteveLevitt Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

In this "Ask Me Anything" (AMA) episode, Peter and Bob take a deep dive into olive oil. They explore the history of olive oil, discuss observational data that led to the hypothesis that olive oil is a healthier alternative to many other fats, and they explain the classification of olive oil types —including what to look for in a high-quality "extra virgin" olive oil. Peter and Bob round out the discussion with a "two-minute drill," in which Peter answers questions from subscribers. They cover zone 5 training, an update on Peter's book, lactate meters, standing desks, massage guns, electrolyte supplementation, and more.

If you're not a subscriber and listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #21 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

• The early history of olive oil and the Mediterranean diet (2:15);
• The three broad categories of fats: SFA, MUFA, and PUFA (6:25);
• Exploring the hypothesis that olive oil is healthy (10:30);
• Comparing olive oil to the makeup of other common oils (30:00);
• Defining "extra virgin" olive oil, what to look for when purchasing, and Peter's favorite brand (34:30);
• Update on Peter's book (47:15);
• Zone 5 training: Peter's approach to zone 5 training, and other anaerobic training protocols (49:30);
• Advantages of using a standing desk compared to sitting (55:30);
• Lactate meters and strips (57:45);
• Electrolyte supplementation during fasting and ketosis, and why uric acid may increase (59:30);
• The usefulness of massage guns, foam rollers, and professional massage for muscle pain and tightness (1:01:30); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/ama21/ Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Michael Rintala is a sports medicine chiropractor and one of only 18 international instructors teaching dynamic neuromuscular stabilization (DNS) for the Prague School of Rehabilitation. This episode focuses on understanding DNS, including the foundational principles and how it relates to human motor development. Michael also shares the most common injuries and issues he sees in patients in his practice, such as postural problems and back pain, and how the movements of a DNS program are used to avoid injury, maintain longevity, and improve sports performance.

We discuss:

• Michael's background in chiropractic sports medicine and rehabilitation (3:15);
• The Prague School of Rehabilitation, and functional rehabilitation as the foundation of the dynamic neuromuscular stabilization (DNS) program (5:00);
• Foundational principles of DNS, and the role of the diaphragm in muscular stability (19:00);
• Types of muscle contractions (28:15);
• Human motor development through the lens of DNS, and when issues begin to arise (32:30);
• Common postural syndromes (50:00);
• Increasing functional threshold to minimize time in the functional gap (56:45);
• DNS for injuries, pain, pre-habilitation, and performance enhancement (1:03:45);
• Etiology of back pain (1:10:00);
• How a stress fracture in his back led Michael to the Prague School (1:16:00);
• The Prague School curriculum: 3 tracks for certification in DNS (1:20:45); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/MichaelRintala/ Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Alex Hutchinson is a sports science journalist, author of the book Endure—which explores the science of endurance and the real limits of human performance—and former competitive runner for the Canadian national team. In this episode, Alex tells the story of his "aha moment" during a meaningless track meet that catapulted his running career and seeded his interest in the power of the mind. He then explains the science behind VO2 max, the difference between maximum aerobic capacity and efficiency, and extracts insights from examples of extreme human performance, such as the recent attempts to break the 2-hour mark in the marathon. Finally, he brings it back to what this all means for the everyday person: optimal exercise volume for maintaining health, how to avoid acute and chronic injuries, how to diversify your exercise portfolio, HIIT protocols, and much more.

We discuss:

• Alex's background and passion for running (3:00);
• The power of the mind: Alex's "aha moment" that catapulted his running career (9:00);
• Pursuing a Ph.D. in physics while prioritizing his running career, and doing the hardest thing possible (19:00);
• Career transition to journalism, tips for improving your writing, and insights from the best writers (26:00);
• Breaking down VO2 max: Definition, history, why it plateaus, and whether it really matters (38:15);
• The case study of Oskar Svensson: Why a higher VO2 Max isn't always better, and the difference between maximum aerobic capacity and efficiency (49:15);
• The sub 2-hour marathon: The amazing feat by Kipchoge, and what will it take to "officially" run a 2-hour marathon (1:01:00);
• Comparing the greatest mile runners from the 1950s to today (1:14:45);
• How the brain influences the limits of endurance (1:20:15);
• Relationship between exercise volume and health: Minimum dose, optimal dose, and whether too much exercise can shorten lifespan (1:23:45);
• Age-associated decline in aerobic capacity and muscle mass, and the quick decline with extreme inactivity (1:40:45);
• Strength or muscle mass—which is more important? (1:47:00);
• Avoiding acute and chronic injuries from exercise (1:48:45);
• High intensity interval training: Evolution of the Tabata protocol, pros and cons of HIIT training, and how it fits into a healthy exercise program (1:54:15);
• The importance of understanding why you are engaging in exercise (2:03:00);
• How we can encourage better science journalism and reduce the number of sensationalized headlines (2:05:45); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/AlexHutchinson Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Bill Frist is a nationally acclaimed heart and lung transplant surgeon, former U.S. Senate Majority Leader, and is actively engaged in health policy and education reform. In this episode, Bill takes us through his long and varied career in medicine, politics, and business, which includes establishing the organ transplantation program at Vanderbilt as well as rising from the lowest-ranked member of the U.S. Senate to the Majority Leader in two terms. We discuss some of the most significant moments of his time in the Senate, such as advocating for AIDS prevention programs' funding and addressing complicated issues like stem cell research and the end-of-life issues raised by the Terri Schiavo case. We also hear his first-person account of what happened behind the scenes on September 11, 2001, his frustration with our lack of preparation for the pandemic, and his thoughts about the current state of U.S. politics. Finally, we talk about his current endeavors in health policy and education reform.

We discuss:

• Bill's decision to pursue medicine and do organ transplants (3:40);
• The miraculous nature of organ transplants: History, Bill's work, and the most exciting things to come (12:00);
• Frist's experience building up the heart transplant program at Vanderbilt (21:45);
• The famous rivalry between surgeons Denton Cooley and Michael DeBakey (29:15);
• How the medical field can attract bright young people to pursue medicine (33:00);
• Bill's decision to leave medicine and run for the US senate (38:00);
• The value in having scientists and physicians in Congress (47:30);
• A discussion on whether or not senators should have term limits (55:30);
• The highly polarized nature of politics, and how we can fix it with empathy (1:00:30);
• Bill's time in the Senate and quick rise to Senate Majority Leader (1:05:30);
• The lifesaving impact of the President's Emergency Plan for AIDS Relief (PEPFAR) under George W. Bush (1:15:15);
• How Bill reversed course on his view of the value and morality of stem cell research (1:19:45);
• Complex end-of-life decisions, and Bill's role in the infamous Terri Schiavo case—a story that captures the conflict among law, morality, and improving technology (1:30:00);
• Remembering the events of September 11th from Bill's perspective in the Senate (1:49:45);
• The coronavirus pandemic: Bill's accurate 2005 prediction, and a discussion about future preparedness (1:56:45);
• The divided state of US politics, and how we can come together (2:06:45);
• How experience in medicine and politics is shaping Bill's current endeavors in business, reforming education, palliative care, and more (2:12:45); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/BillFrist Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

In this "Ask Me Anything" (AMA) episode, Peter and Bob discuss all things related to insulin resistance by revisiting the important points made in the fascinating, yet quite technical, episode of The Drive with Gerald Shulman. They devote the entire discussion to understanding the condition known as insulin resistance, how it's measured, how it manifests in the muscle and liver, and ultimately, what we can do about it.

If you're not a subscriber and listening on a podcast player, you'll only be able to hear a preview of the AMA. If you're a subscriber, you can now listen to this full episode on your private RSS feed or on our website at the AMA #20 show notes page. If you are not a subscriber, you can learn more about the subscriber benefits here.

We discuss:

• Explaining the format of this AMA: Extracting insights from Gerald Shulman's masterclass on insulin resistance (2:00);
• The basics of insulin, defining insulin resistance (IR), and gold-standard methods of quantifying IR in the muscle (7:15);
• Practical ways to test for insulin resistance in a normal clinical setting (15:45);
• How insulin resistance manifests in the muscle (23:00);
• The biochemical block in glycogen synthesis—drivers and mechanisms resulting in insulin resistance in the muscle (30:45);
• The disparity in fat oxidation between insulin-sensitive and insulin-resistant individuals (44:45);
• The fate of the ingested carbohydrate in someone who is insulin resistant (51:00);
• The prevalence and clinical phenotype of insulin resistance (1:00:15);
• The role of exercise in mitigating and reversing insulin resistance (1:05:00);
• How insulin resistance manifests in the liver (1:09:15);
• Biggest takeaways: what we can do to mitigate and prevent insulin resistance (1:20:45); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/ama20/ Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.

Richard Miller is a professor of pathology and the Director of the Center for Aging Research at the University of Michigan. He is one of the architects of the NIA-funded Interventions Testing Programs (ITPs) animal study test protocol. In this episode, Rich goes through the results of the long list of molecules tested by the ITP—including rapamycin, metformin, nicotinamide riboside, an SGLT-2 inhibitor called canagliflozin, and more. Many of the discussed outcomes have had surprising outcomes—both positive and negative findings.

We discuss:

• Rich's interest in aging, and how Hayflick's hypothesis skewed aging research (3:45);
• Dispelling the myth that aging can't be slowed (15:00);
• The Interventions Testing Program—A scientific framework for testing whether drugs extend lifespan in mice (29:00);
• Testing aspirin in the first ITP cohort (38:45);
• Rapamycin: results from ITP studies, dosing considerations, and what it tells us about early- vs. late-life interventions (44:45);
• Acarbose as a potential longevity agent by virtue of its ability to block peak glucose levels (1:07:15);
• Resveratrol: why it received so much attention as a longevity agent, and the takeaways from the negative results of the ITP study (1:15:45);
• The value in negative findings: ITP studies of green tea extract, methylene blue, curcumin, and more (1:24:15);
• 17α-Estradiol: lifespan effects in male mice, and sex-specific effects of different interventions (1:27:00);
• Testing ursolic acid and hydrogen sulfide: rationale and preliminary results (1:33:15);
• Canagliflozin (an SGLT2 inhibitor): exploring the impressive lifespan results in male mice (1:35:45);
• The failure of metformin: reconciling negative results of the ITP with data in human studies (1:42:30);
• Nicotinamide riboside: insights from the negative results of the ITP study (1:48:45);
• The three most important takeaways from the ITP studies (1:55:30);
• Philosophies on studying the aging process: best model organisms, when to start interventions, which questions to ask, and more (1:59:30);
• Seven reasons why pigs can't fly (2:08:00); and
• More.

Learn more: https://peterattiamd.com/ Show notes page for this episode: https://peterattiamd.com/RichardMiller Subscribe to receive exclusive subscriber-only content: https://peterattiamd.com/subscribe/ Sign up to receive Peter's email newsletter: https://peterattiamd.com/newsletter/ Connect with Peter on Facebook | Twitter | Instagram.